Minnesota Small Group Certificate of Coverage Help understanding this document is free. If you would like this Certificate in another format (for example, a larger font size or a file for use with assistive technology, like a screen reader), please call us at (800) 752-5863 (toll-free) | TTY/TDD: (877) 652-1844 (toll-free). Help in a language other than English is also free. Please call (800) 892-0675 (toll-free) to connect with us using free translation services. Sanford Health Plan MN Small Group COC HP-0335 1-20 Table of Contents Free Help in Other Languages .................................................................................................................1 Notice of Privacy Practices ..................................................................................................................... 4 Introduction ............................................................................................................................................................. 6 How to Contact Sanford Health Plan ..................................................................................................... 6 Member Rights ....................................................................................................................................... 6 Member Responsibilities ........................................................................................................................ 7 Medical Terminology .............................................................................................................................. 7 Definitions .............................................................................................................................................. 7 Conformity with State and Federal Laws ............................................................................................... 7 Important Member Information ............................................................................................................... 8 Special Communication Needs .............................................................................................................. 8 Translation Services .............................................................................................................................. 8 Services for the Deaf, Hearing Impaired, and/or Visually Impaired ....................................................... 8 Fraud ...................................................................................................................................................... 8 Clerical Error .......................................................................................................................................... 8 Value-Added Program ........................................................................................................................... 9 Limitation Period for Filing Suit .............................................................................................................. 9 Notice of Non-Discrimination ................................................................................................................. 9 Entirety of the Agreement ...................................................................................................................... 9 Section 1. Enrollment ...........................................................................................................................................10 When to Enroll......................................................................................................................................10 How to Enroll ........................................................................................................................................10 Notice of Non-Discrimination Due to Health Status .............................................................................10 When Coverage Begins .......................................................................................................................10 Eligibility Requirements for Dependents ..............................................................................................10 When and How to Enroll Dependents ..................................................................................................11 When Dependent Coverage Begins ....................................................................................................11 Noncustodial Subscribers ....................................................................................................................12 Qualified Medical Child Support Order (QMCSO) Provision ...............................................................12 Special Enrollment Rights ....................................................................................................................13 Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) ................................... 13 Section 2. How you get care ............................................................................................................................... 14 Identification cards ............................................................................................................................... 14 Conditions for Coverage ...................................................................................................................... 14 In-Network Coverage ........................................................................................................................... 14 Second Opinions .................................................................................................................................. 15 Referrals............................................................................................................................................... 15 Appropriate Access .............................................................................................................................. 15 Benefit Determination Review Process ................................................................................................ 15 Utilization Review Process ................................................................................................................... 16 Prospective (Pre-service) Review of Services (Certification/Prior Authorization) ................................ 16 Services that Require Prospective Review/Prior Authorization (Certification) ..................................... .17 Prescription Drugs that Require Prior Authorization ............................................................................ 18 Prospective (Prior Authorization/Certification) Pharmaceutical Review Requests and Exception to the Formulary Process ............................................................................................................................... 19 Standard Pharmaceutical Exception Requests ................................................................................... 19 Expedited Pharmaceutical Exception Requests .................................................................................. 19 Standard Prospective Review Process for Medical Care Requests .................................................... 19 For Standard Medical Care Requests .............................................................................................. 19 For Standard Benefit Determination Requests ............................................................................... 19 Process for Urgent and Emergency Care Situations ........................................................................... 19 Urgent Care Situations ......................................................................................................................... 19 Emergency Services ............................................................................................................................ 19 Expedited Care Requests and Reviews .............................................................................................. 20 Expedited Care Requests .................................................................................................................... 20 Expedited Care [Prospective (Pre-service)] Reviews .......................................................................... 20 Concurrent Review Process for Medical Care Requests ..................................................................... 20 Expedited Concurrent Reviews Requested Within Twenty-Four (24) Hours of an Expiring Authorization 21 Sanford Health Plan MN Small Group COC HP-0335 1 -20 Retrospective (Post-service) Review Process for Medical Care Requests .........................................21 Written Notification Process for Adverse Determinations ....................................................................21 Section 3. Covered Services – OVERVIEW ...................................................................................................... 23 Section 3(a) Medical services and supplies provided by health care Practitioners and Providers .................25 Section 3(b) Services provided by a Hospital or other Facility ...............................................................................40 Section 3(c) Emergency services/accidents ...............................................................................................................45 Section 3(d) Mental health and substance use disorder benefits ..........................................................................47